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Get TX H1836-B 2006

Texas Health and Human Services Commission Form H1836-B January 2006 Medical Release/Physician s Statement Section I To Be Completed By Staff Name of Patient Date of Birth Social Security No. Case Name caregiver Case No. Patient s Usual Job Advisor s Name BJN - Office Address/Mail Code/Fax No. The person caring for the patient named above has applied for benefits with our agency. If necessary provide further detail Part B Diagnosis Primary disabling diagnosis Secondary disabling diagnosis Comments Name of Physician please type or print Physicians License No. Signature-Physician Area Code and Telephone No. Date Page 2/01-2006 Authorization to Release Medical Information Patient s Name The applicant is requesting an exemption from participating in the employment services program because he/she is needed in the home due to your disabling illness or injury. When you sign this authorization you are giving HHSC permission to contact your doctors medical facilities or other health care providers to request copies of you health information as indicated below. You must sign this form if you want the applicant to be eligible for an exemption from the employment services program. I authorize Doctor Medical Facilities or other Health Care Providers to complete Form H1836-B Medical Release/Physician s Statement and release the information to HHSC and the Texas Workforce Commission for purposes of verifying that the applicant is needed in the home due to my disabling illness or injury and therefore cannot participate fully in the employment services program. This authorization expires on Patient or Personal Representative s Signature If you are signing for the patient please describe your authority to act for the patient Note If the person requesting the release of case information cannot sign his/her name two witnesses to his/her mark X must sign below Witness Notice to Client HHSC as receiver of this information will protect your personal health information in accordance with federal and state privacy regulations. When you sign this authorization you are giving HHSC permission to contact your doctors medical facilities or other health care providers to request copies of you health information as indicated below. You must sign this form if you want the applicant to be eligible for an exemption from the employment services program. I authorize Doctor Medical Facilities or other Health Care Providers to complete Form H1836-B Medical Release/Physician s Statement and release the information to HHSC and the Texas Workforce Commission for purposes of verifying that the applicant is needed in the home due to my disabling illness or injury and therefore cannot participate fully in the employment services program. This authorization expires on Patient or Personal Representative s Signature If you are signing for the patient please describe your authority to act for the patient Note If the person requesting the release of case information cannot sign his/her name two witnesses to his/her mark X must sign below Witness Notice to Client HHSC as receiver of this information will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties it may no longer be protected by privacy regulations. You must sign this form if you want the applicant to be eligible for an exemption from the employment services program. I authorize Doctor Medical Facilities or other Health Care Providers to complete Form H1836-B Medical Release/Physician s Statement and release the information to HHSC and the Texas Workforce Commission for purposes of verifying that the applicant is needed in the home due to my disabling illness or injury and therefore cannot participate fully in the employment services program. This authorization expires on Patient or Personal Representative s Signature If you are signing for the patient please describe your authority to act for the patient Note If the person requesting the release of case information cannot sign his/her name two witnesses to his/her mark X must sign below Witness Notice to Client HHSC as receiver of this information will protect your personal health information in accordance with federal and state privacy regulations. If you authorize release of your health information to other parties it may no longer be protected by privacy regulations. You can withdraw permission you have given your doctor or health care provider to use or disclose health information that identifies you unless they have already taken action based on your permission. You must withdraw your permission in writing. .

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